Provider Demographics
NPI:1467829663
Name:BETHANY MEDICAL CENTER
Entity Type:Organization
Organization Name:BETHANY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LENIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-883-0029
Mailing Address - Street 1:507 N LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4303
Mailing Address - Country:US
Mailing Address - Phone:336-883-0029
Mailing Address - Fax:336-899-2188
Practice Address - Street 1:575 N PATTERSON AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4101
Practice Address - Country:US
Practice Address - Phone:877-722-8910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY ADVANCE DIAGNOSTIC LAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D2089959291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory